Throughout this series, I’ve documented just some of the big, elephantS in the health care room that truly concern me as a physician, patient, son, brother, citizen, and person. I’ve suggested abstract and theoretical policy ideas for how they might improve things, while providing very little practical information on how they might be implemented (tax hikes, law changes, policy changes). Because I’m skeptical that any of them would ever happen in today’s health care environment.

We need a single-payer for all the reasons I’ve stated in the previous post. But we need a single-payer even more to provide some sort of direction in this damn train wreck of a health care non-system in America. Pick almost any issue I’ve mentioned–or haven’t–that concerns you, and ask yourself if you think it’ll go anywhere without some sort of organized plan or director at the helm.

As I said at the beginning, the goal of a country’s health care system–and note, we talk about a country’s health care system, because the whole country’s population is affected by it–should be to make its citizens the healthiest they can be. Right now we have a system that maximizes profit; this coinflip sometimes comes out with also optimal healthiness, but often it couldn’t care less if it makes its patients healthy. Case in point: the Hepatitis C outbreak in Nevada at a colonoscopy center, where 40,000 people may have been exposed to hepatitis and HIV because staff were re-using syringes to save money. Or the woman who finally sued and beat the pants off Blue Shield of California because they dropped her coverage when she started chemo for her breast cancer. (Sick people cost money!)

We currently have a system where each health care player is trying to pull the system in a different direction, and it really leads us to gettiing nowhere, fast. The private health insurance companies certainly have no interest in bigger national goals, since they for the most part don’t have huge national markets. 30% of people change health insurance each year (no surprise when people change employers so often these days). So it’s no wonder that the HMOs aren’t interested in having comprehensive preventative care or an electronic medical record: long-term benefits of long-term programs aren’t ever seen by these companies–their patients have gone to another HMO!

There are a ton of perverse incentives in our current health care system, and at least in health care, it’s worse for all of us. Hopsitals currently advertise that they have the best heart centers, the fastest ERs, etc.–hoping that they can make more money and often just keep themselves open (rightly so: what good is a closed hospital to its community)? So hospitals have invested heavily in profit-making centers–heart centers, new scanners, etc–while providing fewer resources to other more broadly-useful services like primary care. But since there’s no one at the helm analyzing the data saying, “Wow, this community could really use a new rehab unit, since it has a very high number of returning Iraq war vets,” no hospital has any reason to build a rehab unit–unless they can make it profitable. Again, money/profit is a top priority, not health care needs.

And when hospitals aren’t able to compete, they close. And hospitals over the past 30 years have typically closed in the poorest neighborhoods (which often have the sickest patients). So then these patients are now without a hospital and without a doctor. Which eventually makes it worse for all of us.

People Want Reform.
Look, take a gander at any recent poll on health care, and you’ll see that people recognize that this system is in trouble. Whether it uses the words “single-payer” or “national health care system” or “significant change,” significant change is going to happen. It’s just what kind of change. And as I’ve said before, if we don’t take an active role as the nation’s health care providers saying what we think is best for Americans’ health, some system worse than what we can even imagine will fall into place.

It’s not just the uninsured that are voting in these polls–it’s the insured, too. And I believe for people with insurance to put their faith in a new system, it has to offer them something better than what they’ve currently got. And that’s why I’ve made the case for single-payer: it would provide some level of leadership and direction for our health care system, and, because of that, I believe would drastically improve our health care system.

Why Would It Be Better

Better health service, policy, and epidemiological research. We could use some nationalized system to collect anonymous data to see how people do with condition X or treatment Y. Currently a lot of this data is confined to the Medicare or VA populations, which are often not good representations of the entire populations.

Doctors would have more time with patients. Currently so much time is spent with paperwork that doctors spend less time with patients, and have less time to keep up current data and research in the journals.

All the reasons stated above, including people never going without health insurance. I find it interesting that we can be frustrated with Medicare’s “never events” at an institutional level, but don’t apply that same perspective to individual patients. In a perfect world, should no one at a hospital fall and break their hip? Sure, but it’ll happen, no matter how hard we try to stop it. Similarly, should people never get sick when they’re uninsured? Sure, but it’s going to happen, and should they be forever punished for it? I don’t think so.

Single-Payer Won’t Solve EverythingThroughout this series, I’ve presented a number of concerns for this health care system, without really mentioning “single-payer” as a solution, because it alone is not. Health care financing alone will not solve all the problems of health care in this country, but it will be a big step in the right direction. With a single-payer system there would motivation to fix the health care system, as we would have a publicly-financed system whose goal is to optimize our health care system in every way possible.

I don’t buy the argument that “all government is bad.” There are certainly good laws out there, and certainly bad ones. The No-Call List law has been amazingly successul; the NIH is a government organization that divides up billions of dollars a year for medical research; fire and police departments keep us safe, and libraries provide their communities with access to books and information. I certainly don’t believe that any of these would be greatly improved by privatizing them and adding a profit component.

Would single-payer (or any big health care reform change) cause massive changes in our health care system? Absolutely, but I believe to solve or improve many of our health care problems we need massive change. Massive change happened when we gave women the right to vote, or decided that segregation wasn’t acceptable, but I’d argue we all now view these things as fundamentally improving society.

Many of you I’m sure will not be convinced by my arguments. That’s fine. But if that’s the case, it’s your job to come up with a better answer that also has the ability to address the other issues this country is facing besides just paying for health care.

(For example: ED docs love to bitch about EMTALA and people taking ambulances because gas is expensive, but I have yet to see other reasonable ideas for solutions from them.)

Comments

[...] Like I said. Probably really nothing new if you’ve ever read any single-payer stuff on the Internets or my blog in particular. But I’m here to propose a different, and much more important reason we should adopt single-payer. We can’t afford not to. On To Single-Payer, Part 2 [...]

Eric:

Graham, I love you dearly. . . in unholy and impure ways in my fevered mind, in fact, but I don’t know how to say this gently….you’re incredibly dead-wrong on this one.

The reality that healthcare finance (and to some extent, delivery, especially in primary care) is broken is not enough of a reason to implement national single-payer.

If we set it up as a categorical syllogism, your argument goes something like this:

Major Premise: The system is wildly expensive.

Minor Premise: The system deprives some people of needed/useful care while lavishing it on others who may not benefit from the spending.

Conclusion: We should junk the way we finance it and let the government run the whole thing.

The premises just don’t support the conclusion. The premises support that the system needs massive fixing, but it doesn’t lead to a particular solution, let alone the most drastic of all the options.

I totally don’t understand the value of removing free market innovation from the equation. Not all insurers (oh, let’s be blunt: healthcare finance brokerage houses) are for-profit enterprises. Some not-for-profit insurers do pretty good at keeping members healthy and delivering appropriate care – Group Health here in Seattle being one of them. Can’t fault the way they value primary care. The customer service I get from my family’s for-profit insurer is above-average – better than I get from the Medicare intermediary for our state, in fact, worse than I get from the cable company. It’s one reason I’d switch to another carrier – better phone service, or a better online presence. Without the ability to migrate to someone else, there’s no incentive to improve customer-facing functions. Monopolies suck. About the only product in the US that you can’t buy from a plethora of providers is nuclear fuel, and seriously, the gubmint does *not* do a stunning job running that bidness.

Healthcare wasn’t imploding when the Blues ran the show. Yes, the argument can be made that we didn’t have as many clever interventions or imaging tools as we do now. However, a large part of the success (and eventual decline) of the Blues was the community rating aspect – everybody was in the pool, rates were set by age and gender.

The death of this model, of course, was improved underwriting technology that let for-profit insurers cherry-pick healthy groups out of the pool by offering marginally lower rates with very low risk of having to pay large claims. Now we enter actuarial death spiral, with organizations and individuals staying in the Blue pools as insurer of last resort.

So, yeah, I’m a shameless capitalist. And I’m also in the unfortunate position of caring for a couple people who are heavy users of healthcare services. I just can’t fathom having to navigate a bureaucracy where you don’t truly have the option of switching to another provider when the customer service degrades to rat dung.

So what do we do? Well, aside from being a shameless capitalist, I think big and have all the answers. . . . ;0)

1) We stop letting carriers cherry pick. All plans are available to everyone who is willing to pay the rate for their age and gender and broad geographic area – somewhere between “area code” and “state”, not “zip code”.

2) We stop letting the young/healthy/wealthy opt out. Everybody has to have healthcare finance of some sort even if it’s a minimum catastrophic benefit.

3) Employers get the pools off their books. No more “self-insurance” and no more limitless retiree healthcare liabilities, either. Everybody gets in to plans that everybody can buy. Volume purchasers can negotiate a small discount for EFT payments or for taking on some aspect of the administration, but no fair being, say Google, and self-insuring your young/healthy workforce and not having to kick in a lil’ somethin’ for the sick old mainframe geeks.

4) Further refine the XML and interchange standards for healthcare data, so that electronic claims submission and adjudication is mandatory. There’s absolutely no reason paper needs to be part of the payment equation. Providers and consumers should be able to know, in advance, if something is covered and at what level.

5) Set a minimum standard for what catastrophic and comprehensive coverages actually cover, and apply that across all geographies. Take the lead of the Federal Employee Health Benefit program, which has a broad set of coverage requirements, resulting in a High Option, a Low Option, an HMO and a CDHP/HSA-like option.

6) Require that all plan documents and marketing materials are understandable with a fifth-grade math and reading level.

7) Mandate EMRs for any provider who accepts coverage paid for by any government funds (Medicare, subsidies for the private coverage that would replace Medicaid, government employee benefits, etc). One of the wonders of the Sandwich Spread Clinic system is that their EMR is so good, so thorough and so functional that duplicate labs and imaging simply don’t exist in their system. It’s so intimately tied to billing, scheduling, radiology. . . it gives me tingles. There are some healthcare finance experts who estimate that if everyone it the country could get treated at Sandwich Spread or LDS/Intermountain, we could *CUT* spending 30%, not just hold the line on spending growth. A large part of that savings is in eliminating the duplication and the paperchase.

These are politically achievable goals with realistic results that can slow the growth of spending and increase access to healthcare finance. More importantly, there aren’t perverse disincentives to providing appropriate care. If a private entity can do it and make enough to satisfy shareholders, great. If a nonprofit can? Super. If a state- or county-level government program can? Mazel tov.

I don’t deny we have to do something. I just am vehemently opposed to that “something” being wiping out everything and building a massive bureaucracy that people of typical means can’t avoid.

So many misconceptions in the blog entry and in the responses, it’s hard to know where to start. But here goes:

1.”calling for a single-payer system in the U.S. is about as realistic as asking Americans to stop watching football/baseball and take up water polo as their favorite sport.” This is exactly backwards: Americans actually WANT single payer, according to many polls, but are denied it by politicians beholden to insurance companies. So it’s like we are being forced against out will to watch water polo, when we would prefer baseball or football.

2. “But we need a single-payer even more to provide some sort of direction…”

Single payer does NOT “provide direction” to healthcare providers. Check out HR 676. Providers are free to do whatever they want to attract patients, who have free choice of provider—more than they have today. Single payer just does what it says: it pays the providers. Allocation of fees is worked out with the provider community. Overall spending levels are approved from time to time by voters.

3. “Without the ability to migrate to someone else, there’s no incentive to improve customer-facing functions” Agreed. But who says single payer doesn’t let you migrate? You have a totally free choice of provider, whereas now, with either PPO’s or HMO’s, you don’t. Again, exactly backwards.

4. “…wiping out everything and building a massive bureaucracy…” Again, backwards.
The healthcare providers don’t get “wiped out” in single payer, and the exisitng administrative hassles are cut dramatically. What goes is the whole insurance company-induced bureaucracy now eating up 1/3 of premium payments, costing us over $300 billion per year.

I, too, am a “shameless capitalist,” as was Friedrich Hayek, patron saint of free marketers. But I agree with Hayek that it does make sense to “collectivise” healthcare, along with police, fire protection and the military. And the best way to do that is with single payer, as in HR 676.

What Americans fail to understand is that for single payer to be successful Americans have to revere the system.
I know this sounds wacky but bear with me. Single payer works in Canada and everywhere else for only one reason and it’s not quality or cheapness or anything but this: the belief health care is a National TREASURE.

And because Canadians on the whole are way more financially conservative than any American Republican could dream of being we mean treasure in the pirate sense of the word.
Once doesn’t try to rip off or take advantage of your own treasure because you are only hurting yourself.
We look at our health care system like a chest filled with gold.
We worship it and understand we have only one chest and no one is coming with another one. Yes, even the poor and disenfranchised believe this.
The majority opinion is don’t abuse the system because we are only abusing ourselves.
Americans can’t get into this kind of thinking ever. Americans believe there is always another chest of gold if this one runs out and it’s that kind of cultural thinking that will sink a single payer system. The prevalence of the overly entitled seems to be a majority share issue in the US according to the ER blog world(not a scientific poll though) and that will kill the single payer system dead.
To maintain the single payer system it has to be loved in a crazy nationalistic way so it will be protected and supported. If everyone wants it to succeed and believes implicitly that it will it forces all politicians and people to respect it.
Your politicians only pay lip service to anything and only for as long as they are looking for votes.I can guarantee no politician will effectively follow through with the needs and demands of a single payer system once they get elected.If they can’t show the respect it demands than the general public wont bother either. Disrespect for the providers and the system will cripple it.

You do not have the cultural or the political will to nurture and protect this system.
Forget it.
Stick with big business love of profit, it fits your culture better..work within that system and some success may be possible…move to single payer and it’s guaranteed to be a lack luster half assed attempt that gets junked within months.
Single payer takes a country willing to sacrifice, have patience and be willing to listen and work together for the good of all it’s citizens even if it is hard.
You guys aren’t that interested in a health care solution.
Give it another twenty years..they always say change can only come when someone has personally felt enough pain that it is more painful NOT to change.
At least half the population of the US is feeling no pain at all so there is no incentive for them to change, one quarter is feeling a little pinch here and there and the remainders have no voice to go with their no health care so no one cares about what they are saying.
When 75% are feeling pain you might be ready to look at changes, until then there isn’t any need for discussion as it’s just political mind f@*king. A quaint distraction from the heap of elephant poo in the room which is the destruction of the US economy by funding a war using a credit card with a 28% repayment rate and no money down .
Health care always gets the “change” pr spin in every presidential election feeding frenzy when something egregious is happening that needs to be overlooked.

Welcome!

This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.

I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!